Aspergillus sp. found most commonly in patients with underlying asthma or cystic fibrosis. Host factors which alter the innate and adaptive immune responses to this abundant airborne fungus contribute to the development of chronic airway inflammation, bronchiectasis, and fibrosis. Traditionally, treatment has focussed on reducing fungal burden and immune response to fungal antigens. However, a significant proportion of patients continue to suffer recurrent exacerbations with progressive lung damage, and the side effect burden of existing treatments is high. New treatments including novel antifungal agents, monoclonal antibodies against aspects of the adaptive immune response as well as targeted immunotherapies may be better tolerated and achieve improved outcomes but have not yet been studied in large-scale randomised control trials.Allergic bronchopulmonary aspergillosis is an allergic pulmonary condition caused by hypersensitivity to antigens of  Aspergillus. The most common pathogen in this genus, Aspergillus fumigatus, is abundant in both indoor and outdoor environments and does not usually cause disease in immunocompetent individuals.2 In immunocompromised individuals or in those with underlying lung disease however, it can cause a spectrum of disorders ranging from invasive aspergillosis to allergic aspergillosis. Allergic aspergillosis has been categorised into ABPA and severe asthma with fungal sensitisation.Allergic bronchopulmonary aspergillosis (ABPA) is defined as an allergic pulmonary condition caused by hypersensitivity to allergens of the common saprophytic filamentous fungi et al. in 1952 and is found in patients with asthma and cystic fibrosis (CF), as well as in rarer conditions, such as chronic granulomatous disease and hyper-immunoglobulin E syndrome. Characteristically, individuals with ABPA present with respiratory symptoms including poorly controlled asthma, wheeze, haemoptysis, and productive cough as well as systemic symptoms, such as fever and weight loss and can suffer recurrent exacerbations. In CF patients, ABPA may present with worsening symptoms or lung function that is not responsive to usual antibiotic treatments. ABPA can typically be a cause of large airway collapse and lead to bronchiectasis. In certain cases, ABPA may develop into chronic pulmonary aspergillosis. End-stage disease is typified by cor pulmonale and type-2 respiratory failure.ABPA was first described by Hinson  The prevalence in severe asthma is likely to be much higher, for example, a prospective study of patients with severe asthma attending a tertiary centre clinic in Northern India showed a prevalence of 70%. The prevalence of ABPA complicating asthma in the United Kingdom is predicted to be between 50,000 and 250,000. Studies on CF have found a wide prevalence range between 2% and 19% dependent on definition criteria.13The estimated prevalence of ABPA in asthma depending on definition criteria is between 0.7% and 22%, and therefore is likely to affect 4.8 million patients globally.In this review, we describe the diagnostic criteria and pathophysiology of ABPA, current therapeutic options, and future potential therapeutic targets. the ISHAM criteria , and one proposed more recently by Asano et al., as well as a modified ISHAM criteria based on latent class analysis proposed by Saxena et al. There are different criteria used for patients with CF (proposed by the CF Foundation) due to overlapping clinical features with bacterial exacerbations in CF, and for patients with allergic bronchopulmonary mycosis (ABPM).16The diagnosis of ABPA is based on a combination of clinical, serological, and radiological features. There are several criteria proposed for diagnosis including the Rosenberg–Patterson criteria,Aspergillus skin tests, sputum cultures, peripheral eosinophilia, total serum immunoglobulin E , A. fumigates-specific IgE, A. fumigates-specific immunoglobulin G (IgG), and radiological findings. Various cut-off values for these investigations have been proposed as several of these investigations may be abnormal in other fungal or related diseases, and there can be difficulties with the effects of treatment on some parameters.These criteria use the results of several investigations to aid diagnosis, including 1618 Total serum IgE levels can be used to monitor treatment with reductions in IgE of 25–50% correlating with improved symptoms and radiological appearances and increasing levels (e.g. a doubling in IgE level) suggesting an impending exacerbation. In addition, lung function can be used to determine the severity of underlying lung disease and monitor response to treatment. Fixed airflow obstruction and reduced lung volumes can be found in progressive disease. Sputum cultures are not diagnostic as they may be positive in patients without ABPA who are colonised with Aspergillus but are important in determining azole resistance prior to treatment.Some of these investigations may also be used in determining exacerbations and monitoring treatment efficacy.21 Mucus impaction is another common finding on computed tomography (CT) imaging and high attenuation mucus  is a pathognomonic feature of ABPA.2225Central bronchiectasis  is the defining radiological feature of ABPA and is part of the Rosenberg–Patterson and Asano diagnostic criteria.et al. in 1982. This staging involved five categories: acute, remission, exacerbation, steroid dependent asthma, and fibrotic lung disease. The International Society of Human and Animal Mycology (ISHAM) group proposed a new staging system, with seven stages ranging from 0 (asymptomatic) to 6 (advanced ABPA) as described in ABPA was originally staged by Patterson 27 This divides patients into four stages with differing radiological appearances. These include ABPA-S  which includes all diagnostic features of ABPA but no abnormality on CT, ABPA-B (ABPA with bronchiectasis), ABPA-HAM (ABPA with high attenuation mucus), and ABPA-CPF (ABPA with chronic pleuropulmonary fibrosis) which includes other radiological features including pulmonary fibrosis, parenchymal scarring, fibrocavitatory lesions, aspergilloma, and pleural thickening without the presence of mucoid impaction or HAM. In a study of 234 patients which were categorised in this way, the immunological severity also increased between the stages. These studies show clearly that ABPA represents a heterogeneous group of endotypes which will likely be important in evaluating future novel therapeutic strategies.Radiological staging has also been proposed by the ISHAM group. Treatment can be effective in maintaining lung function and lack of treatment or late diagnosis can lead to progressive and even fatal disease.30 Therefore, early diagnosis and treatment of ABPA is crucial in preventing the development of serious and potentially irreversible lung damage, such as bronchiectasis or fibrosis.There are limited studies on the long-term prognosis of ABPA. In a study following 120 patients over 4 years, 33% went into remission, 20% became steroid dependent, and 2% developed end-stage fibrotic lung disease.A. fumigatus is the most common pathogen involved in ABPA but other species including A. flavus, A. niger, and A. oryzae may also be involved. Other fungal species including Schizophyllum commune may cause similar pathology to ABPA, and this disease is termed ABPM.33A. fumigatus produces tiny (2–5 micrometre) spores, known as conidia, which are able to remain in the atmosphere for long periods of time and are therefore inhaled in large numbers.34A. fumigatus is ubiquitous in the environment and does not cause disease in most individuals. It is clear therefore that disease is caused by host factors, including genetic predisposition, which affect the host response to Aspergillus by affecting innate and adaptive immune responses. It is these innate and adaptive immune responses that are the current targets for treatment of ABPA, as well as treatment to reduce fungal burden.Aspergillus conidia to swell and develop hyphae. Innate immune systems are involved in preventing this by acting to clear fungal spores from the airways.Innate immune responses include non-specific physical, chemical, and cellular responses to pathogens, and defects in these processes have been shown to be involved in the pathogenesis of ABPA. A key factor in the development of disease is the ability of  and therefore results in defective clearing of Aspergillus spores from the airway, predisposing patients to ABPA. Aspergillus itself is also involved in reducing the efficacy of the mucociliary escalator. For example, Aspergillus produces metabolites such as gliotoxin which impair ciliary beating.The first innate barrier to infection is the airway epithelium. In larger airways, the epithelial layer contains goblet cells and ciliated cells. Goblet cells produce mucus which traps foreign bodies , and ciliated cells move the mucus up the airways towards the mouth, where it can be coughed up or swallowed. This mucociliary escalator is impaired in individuals with CF or asthma CF patients are known to have an increased risk of ABPA, and evidence has been found that mutations in the CFTR gene (insufficient for a diagnosis of CF) are associated with ABPA in asthmatic patients. Evidence from pooled results from four studies showed an increased likelihood of encountering CFTR mutations in patients with ABPA. The viscosity of mucus is another target in the treatment of ABPA.The composition of mucous may also be a factor predisposing to ABPA. Polymorphisms in the Cystic Fibrosis Transmembrane Conductance Regulator (CFTR) gene, which regulates the flow of sodium and chloride ions across cell membranes, affect the viscosity of mucous and increase the risk of ABPA.Aspergillus. Eosinophils undergo cytolysis and release filamentous chromatin fibres .40 EETs act to immobilise Aspergillus via hydrophobic interactions; however, EETs may also contribute to increased mucus viscosity and sputum plug formation. A case report showed abundant EETs in mucous plugs found in a patient with ABPA, and a significant reduction in EETs once the patient was treated with steroids. In addition, there is evidence that EETs are not effective in killing Aspergillus, and so may contribute to pathogenesis.ABPA is characterised by eosinophilic recruitment to the airways and peripheral eosinophilia. Eosinophils have recently been shown to undergo a process of extracellular trap cell death in response to Aspergillus conidia and target them for phagocytosis by neutrophils and macrophages.44 Genetic polymorphisms that cause changes in the collagen region of surfactant protein A2 have been shown to be associated with increased levels of IgE and increased eosinophilia compared to patients with ABPA who lacked these single-nucleotide polymorphisms (SNPs), suggesting that changes in the function of surfactant proteins may contribute to worsened disease.A further innate immune response occurs within the smaller airways, where Type-II pneumocytes are responsible for secreting surfactant proteins, including surfactant proteins A and D. In addition to their other functions, these act as opsonins that bind A. fumigatus innate responses,47 which they detect via pattern recognition receptors (PRRs). These receptors, located on the cell wall detect pathogen-associated molecular patterns (PAMPs) including B glucan, chitin, and galactomannan. Toll-like receptors (TLRs) are located within the plasma membranes of cells and on intracellular endosomes and detect PAMPs on the fungal cell wall. Binding to these receptors, triggers secretion of pro-inflammatory cytokines, and TLR activation on dendritic cells causes propagation of an adaptive immune response. Genetic polymorphisms in TLR3 and TLR9 and mannose binding lectin have been shown to cause susceptibility to ABPA, and TLR agonists have been considered as adjuvants in allergy immunotherapy treatment including in ABPA.4851A number of other innate cells including alveolar macrophages, neutrophils, monocytes, and dendritic cells are involved in  While there are no studies on ILC2s in ABPA specifically it is likely that these cells which respond to allergen exposure and when activated cause release of type-2 cytokines (including interleukin (IL)-5 and IL-13) resulting in eosinophilia and mucus hypersecretion may also be involved in the pathogenesis of ABPA and therefore may be a future therapeutic target. A recent study showed that in a murine model of eosinophilic asthma, inhibition of ILC2s by 2’3’-cGAMP resulted in decreased airway hyper-responsiveness and lung eosinophilia in response to challenge with Aspergillus flavus, suggesting that inhibition of ILC2s may reduce type-2 inflammation in patients with ABPA.Innate lymphoid cells (ILCs) are a recently discovered group of innate immune cells, and group-2 ILCs (ILC2s) have been shown to have a significant role in allergic diseases including asthma. The host response to Aspergillus in ABPA however is skewed towards a Th2 response, and this is thought to cause progressive disease. Th2 responses counteract Th1 responses and promote IgE and eosinophilic responses. Th2 cytokines include IL-4, IL-5, IL-10, and IL-13. IL-4 stimulates activated B cells and promotes differentiation of B cells into IgE producing plasma cells. IL-5 is a mediator for eosinophil production and activation. IL-13 induces airway hyper-responsiveness, goblet cell metaplasia, and mucous hypersecretion. SNPs in IL-4R and IL-13 genes have been shown to be associated with increased risk of ABPA and the 1082GG genotype of the IL-10 promoter has been associated with the development of ABPA in CF patients.58 Monoclonal antibodies have been designed to target aspects of the Th2 inflammatory response and have been shown to be effective in the treatment of ABPA.5962The adaptive host response involves T and B lymphocytes and is pathogen specific. In general, the host response to a pathogen may be either a T-helper (Th) 1 or Th2 response and both cell types produce specific cytokines. Th1 responses are generally pro-inflammatory and involve cytokines, such as interferon gamma (IFN γ), IL-2 and tumour necrosis factor beta (TNF β). Th1 cytokines enhance cytotoxic and macrophage activity and therefore promote fungal clearance.in vitro compared with controls.A. fumigatus has also been shown to generate extensive lung inflammation and an enhanced Th2-biased immune response in CFTR deficient mice compared with controls.As well as affecting the viscosity of mucus, mutations in the CFTR gene have also been shown to affect the adaptive immune response. For example, mutations in the CFTR gene have been shown to be involved in maintaining the balance between Th1 and Th2 responses, with CD4+ T-cells derived from CF patients exhibiting Th2 bias 6567 It is thought that these patients express a major histocompatibility complex/HLA that restrict the phenotype of expression in antigen presenting cells and skews the immune response towards a Th2 response.Observational studies have shown an increased risk of ABPA in patients who express HLA-DR2 and/or DR5 but not HLA-DQ2. HLA-DRB1*1501 and 1503 are associated with higher risk and HLA-DQB1*0201 are associated with lower risk.A. fumigatus also has various mechanisms which drive the adaptive immune response towards a Th2 response rather than a Th1 response. For example, A. fumigatus has been shown to inhibit IFNβ signalling through the JAK-STAT pathway, which leads to a reduction in the chemokine CXCL 10 and drives the response towards a Th2 response. Aspergillus has also been shown to cause activation of certain receptors (protease-dependent receptor 2 and tyrosine-protein phosphate non-receptor type) in bronchial epithelial cells which results in suppression of CXCL 10, promoting a Th2 response,69 in addition to secretion of proteases such as alkaline serine proteases which have elastolytic and collagenolytic activity and cause damage to epithelial cells and airway structural components.7072 Repair mechanisms in response to damage by Aspergillus proteases, mast cell degranulation, eosinophils, and EETs result in proliferation of epithelial cells, endothelial smooth muscle cells and fibroblasts, resulting in remodelling of the airways, and development of bronchiectasis.7375 Due to these factors, antifungal therapeutics aiming to reduce fungal colonisation of the airways are an important consideration in management of ABPA.27 Treatment therefore has traditionally included immune suppression using steroids and antifungal therapy to reduce fungal burden. Novel treatments including monoclonal antibodies, immunotherapy, and novel antifungal agents may be of benefit in the treatment of ABPA but have not been studied in large-scale randomised control trials. A summary of the action of different therapeutic agents in the pathogenesis of ABPA is shown in The overall therapeutic goal of ABPA management is to minimise the pro-inflammatory response and reduce airway fungal burden to control symptoms, reduce exacerbations, maintain and normalise lung function, and prevent radiological progression. The medium-dose regimen consisted of prednisolone 0.5 mg/kg/day for 1–2 weeks, then alternate day therapy for 6–8 weeks, and finally tapering by 5–10 mg every 2 weeks until ceasing after 3–5 months. The high-dose regimen consisted of prednisolone 0.75 mg/kg/day for 6 weeks followed by 0.5 mg/kg/day for 6 weeks. The dose was then reduced by 5 mg every 6 weeks to complete a treatment duration of 6–12 months. A retrospective study in 55 patients with ABPA-S showed that treatment with high-dose steroid regime induced remission (defined as a reduction in serum IgE levels by at least 25%) in all patients at 3 months. This indicates that the use of systemic corticosteroids may be significant in reducing progression to radiologically apparent disease; however, the study has a number of limitations including size, its retrospective nature and the lack of a control group.At present, glucocorticoids are the current mainstay of treatment; however, there is a paucity of clinical trials evaluating effectiveness, dose, and duration. To date, there have been two dose regimens for oral glucocorticoid therapy studied in the literature: medium and high dose. A recent review by Ishiguro et al. into patients with ABPM showed that systemic corticosteroids are also effective in this related condition. Intravenous pulsed steroids have been studied and shown to be beneficial in children with refractory ABPA exacerbations associated with long-term steroid use.79 Although effective, the use of systemic glucocorticoids is limited by significant side effects including obesity, osteopenia, development of type-2 diabetes, insomnia as well as many other effects. In addition, long-term glucocorticoid use can cause downregulation of glucocorticoid receptors inducing a steroid-resistant state.A randomised control trial of 92 patients with asthma found that the medium dose regimen was as effective and less harmful than high-dose regimen in acute ABPA, with no significant difference in time to exacerbation or progression to steroid dependent ABPA. There was in addition a significantly higher number of patients with steroid-related complications in the higher dose group.82 The recommendation of the ISHAM committee was that high-dose inhaled corticosteroids should not be used in isolation in ABPA due to lack of evidence of efficacy.84Inhaled steroids have been investigated in numerous case studies for treatment of ABPA. These studies often included patients on systemic corticosteroids in addition and assessed efficacy in a variety of different ways including radiologically and with lung function, rather than serology.83 Given the significant side effect profile of steroid treatment often antifungal strategies are considered in steroid dependency.Despite corticosteroids being the mainstay of treatment in ABPA, 50% of patients relapse once systemic steroids are reduced and up to 45% become steroid dependent.Aspergillus spore exposure. Patients may therefore be advised to avoid high-risk environments, for example, areas with decomposing matter and mouldy indoor environments. Given the ubiquity of Aspergillus in the environment however, this is unlikely to reduce the fungal burden significantly for most patients. Other strategies to reduce fungal burden include treatment with antifungal agents.As detailed above, antifungal agents have been used in ABPA as it is thought reducing the fungal burden in the airways will reduce the antigenic stimulus and therefore reduce inflammation. The easiest way to reduce fungal burden is to reduce A. fumigatus and are predominantly first-line therapy in the management of Aspergillus-related infection and allergy in chronic respiratory disease. Triazole antifungals include first-generation drugs, including itraconazole and fluconazole and second-generation triazole antifungals, such as voriconazole, posaconazole, and isavuconazole. Ketoconazole was the first antifungal agent used to treat ABPA; however, this has now been largely superseded by itraconazole. In a study comparing itraconazole to placebo in steroid-dependent ABPA, it was shown that itraconazole reduced steroid dose by more than 50% and reduced total IgE levels by more than 25%. There were also clinical improvements including improved exercise capacity, resolution of radiological opacities on chest radiograph and improved spirometry, although these were not statistically significant. A further study in clinically stable patients showed a reduction in sputum inflammatory markers, serum total IgE levels, and frequency of exacerbations with itraconazole.Oral triazole antifungal drugs are effective against versus itraconazole monotherapy in acute ABPA showed no difference in the proportion of patients achieving full remission after 3 and 6 months of treatment and no difference in time to first exacerbation, which the authors suggest shows itraconazole can be used as a steroid alternative. However, their findings did show that steroid treatment resulted in a significantly greater initial response (within 6 weeks), measured as a composite score consisting of improved symptoms, improved chest radiograph appearances and decline in serum IgE by more than 25%. The rate of adverse outcomes however, including cushingoid habitus, weight gain and acne was significantly higher in the steroid group. A limitation of this study was that there was a significant proportion of patients (12%) who did not initially respond to itraconazole and were excluded from subsequent follow-up investigations, with no ability to predict non-response.A study comparing the effectiveness of steroid monotherapy  Itraconazole is a cytochrome P450 inhibitor and therefore may have interactions with other medications including corticosteroids. Therefore, when used in cases of steroid dependency, effectiveness of azole therapy when given in combination with steroids may potentially relate to increased steroid bioavailability. The use of inhaled corticosteroids (e.g. fluticasone and budesonide) can result in adrenal suppression and Cushing’s syndrome.Long-term azole use, however, can have several adverse effects including gastrointestinal (GI) disturbance, hyperlipidaemia, peripheral oedema, peripheral neuropathy, and heart failure. Posaconazole and voriconazole have been shown to induce clinical response in 78% and 70% of patients, respectively, in a study of 25 patients with previous itraconazole treatment failure, with 75% of patients able to discontinue oral corticosteroids, a reduction in serology, healthcare utilisation, and short-term beta-agonist use and improvement in radiological appearances at 9 months. The study also noted significant adverse events with voriconazole (40%) with 26% of patients requiring treatment cessation, with no significant adverse effects with posaconazole.Alternative newer azole medications (e.g. posaconazole and voriconazole) have been used in treatment failure or intolerance with itraconazole.Aspergillus IgE with posaconazole in comparison to corticosteroids only or other azoles, with Aspergillus IgE levels inversely correlated to drug levels. The authors suggest the improved serological response to posaconazole may be due to its improved bioavailability and ability to achieve therapeutic drug levels or enhanced antifungal activity. The study has a number of limitations, however, and randomised controlled trials are required to look at the relative effectiveness of novel azole therapies in ABPA. There are a number of novel inhaled azole compounds in clinical trials with an aim to reduce the systemic side effect profile often related to azole therapy. Itraconazole has been developed as a dry powder inhaler and is currently in phase-II clinical trial. In addition, a novel triazole, PC945 has been shown to be more effective against Aspergillus than voriconazole in vitro and in vivo, has limited systemic bioavailability and is due to commence phase-III clinical trials in 2021.In the CF population, there is some evidence to suggest that posaconazole may be more effective than other triazoles in the treatment of ABPA. A retrospective study of 32 CF patients with ABPA treated with itraconazole, voriconazole, and posaconazole showed a significant reduction in Aspergillus diseases where azole resistance is an issue. Newer echinocandin agents are currently in clinical trial with modified pharmacokinetic properties allowing for reduced frequency administration (e.g. Rezafungin), with phase-3 trials in the setting of invasive fungal disease ongoing. Further novel echinocandin agents with oral bioavailability (e.g. ibrexafungerp) are also in phase-3 clinical trials. Whether these agents will be useful in ABPA management remains to be studied.Other currently available classes of antifungal therapy include the echinocandin group  and the polyenes (e.g. amphotericin). No trials as yet have been conducted into the use of echinocandins in the management of ABPA. However, they have been used in other  It is thought that lipid formulations (e.g. ambisome) may be better tolerated and there is some evidence for its use in paediatric patients with CF.101Amphotericin B in nebulised form has been used in the treatment of ABPA. Nebulised amphotericin (in sodium deoxycholate formulation) was found to be effective in 3 of 21 patients; however, the remaining 18 patients had to discontinue due to bronchospasm.in vitro against Aspergillus and phase-2b clinical trials in the setting of invasive fungal infections are ongoing. Fosmanogepix is a pro-drug of manogepix, which is an inhibitor of the fungal enzyme GPI-anchored wall transfer protein 1 (Gwt1) which is involved in glycolipid biosynthesis and has been shown to have significant in vivo efficacy against Aspergillus. It is currently in phase-2 clinical trials and has shown excellent oral bioavailability, favourable drug–drug interaction and tolerability.There are additionally several completely novel antifungal agents in late phase clinical trials that may potentially be of use in the treatment of ABPA. Olorofim inhibits the enzyme dihydroorotate which is a key step in pyrimidine synthesis. It has been shown to be active Aspergillus additionally produces a variety of different toxins which affect the airway and interact with the host response and there has been interest in these as therapeutic targets in ABPA. Alkaline protease 1 (Alp1) may be an example of a potential new target for treatment in ABPA. This A. fumigatus serine protease has been shown to cause airway hyper-responsiveness, inflammation, and smooth muscle contraction which contributes to pathogenesis of ABPA and is independent of the host immune response. Targeting such secreted products may thus be a novel future approach to managing this complex disease. The dose is dependent on the initial IgE level (0.016 mg/kg/IU) with an upper IgE limit of 1500 IU/mL and a maximum dose of 1200 mg monthly. As serum IgE levels are usually very high in ABPA, large doses are usually required.There is increasing evidence for the use of monoclonal antibodies in treating ABPA. Omalizumab (Xolair) is a humanised monoclonal IgG antibody against IgE. It acts to bind free serum IgE and down regulates cell-surface high-affinity receptors for IgE (FcεR1) on basophils and mast cells. A systematic review which included 102 patients with predominantly prior treatment failure with steroids and antifungals from 30 studies was done to assess the effectiveness of omalizumab. This showed there was a reduction in clinical symptoms, exacerbation rates, steroid use, serum total IgE levels, and FENO following treatment with omalizumab. There was a suggestion that there were greater effects in patients with higher baseline total IgE levels receiving treatment via the subcutaneous route. However, the majority of the data in this study was derived from case reports. Omalizumab has also been reviewed in the CF population. A retrospective study into CF patients with ABPA showed no significant reduction in cumulative steroid dose, days on IV antibiotics or days in hospital. However, a small proportion (4/11 patients) managed to reduce their steroid dose by over 50%. All the studies performed to date in CF and non-CF ABPA are limited by a lack of placebo control, with small patient numbers and often retrospective analysis. Further prospective clinical trials are required to analyse the long-term effectiveness of omalizumab or other anti-IgE monoclonal antibodies (e.g. ligelizumab and quilizumab) in ABPA.A randomised cross-over study evaluated the effectiveness of omalizumab compared with placebo in 13 patients with ABPA and found that there was a significant reduction in exacerbations in the treatment arm and FENO reduced significantly from baseline. There were no adverse events. Subcutaneous mepolizumab 100 mg every 4 weeks was given to all patients. Eosinophil numbers dropped significantly in all patients, but only four patients had a significant reduction in total IgE levels. There were however improvements in FEV1 and radiological findings, and there was a clinical improvement in all patients with no adverse effects identified. Reslizumab and benralizumab also interrupt signalling via IL-5. Reslizumab is a second anti-IL-5 monoclonal antibody and benralizumab is a monoclonal antibody against the α unit of the IL-5 receptor. Both have been shown to reduce blood eosinophil levels in asthma patients with potential efficacy in ABPA. A retrospective study of anti IL-5/5R treatment in patients with severe asthma with fungal sensitisation and ABPA showed a reduction in exacerbations in the ABPA subgroup. However, this study is limited by the small patient numbers in the ABPA subgroup (N = 9) and large randomised controlled trials are required to definitively understand the utility of anti-IL-5 therapy in ABPA.Mepolizumab is a humanised monoclonal antibody to IL-5, which is a key mediator in eosinophil differentiation, activation, migration, and survival. A systematic review evaluated the effectiveness of mepolizumab in ABPA in seven studies, with a total of eight patients. The patient was commenced on dupilumab in addition to high-dose inhaled corticosteroid, long acting beta-agonist and prednisolone 20 mg and symptoms resolved at 4 months. The patient was able to taper steroids successfully, and there was significant improvement in lung function sustained at 8 months. IgE levels and eosinophil levels had also normalised by 8 months. Dupilumab holds significant potential as a therapeutic in ABPA and a phase-III randomised control trial of dupilumab in asthma patients with ABPA is currently underway (NCT04442269).Dupilumab is an IL4-Rα antibody that has been used in atopic dermatitis, severe asthma, and chronic rhinosinusitis and inhibits Th2 cytokine signalling via IL-4 and IL-13. A recent case report documented the use of dupilumab in a patient with ABPA who had previously failed treatment on itraconazole, omalizumab, and benralizumab. Given its actions on Th2-mediated immune responses and airway remodelling it again may show significant promise as a future therapeutic agent in ABPA.Tezepelumab is a monoclonal antibody against thymal stromal lymphopoietin (TSLP) which acts as an upstream mediator of the inflammatory response to common asthma precipitants including viruses, allergens, and other airborne irritants. TSLP acts on multiple aspects of the inflammatory response including allergic inflammation, eosinophilic inflammation, neutrophilic inflammation, and airway remodelling. Tezepelumab has been shown to reduce exacerbation rates, improve lung function and reduce symptoms in patients with a wide variety of asthma phenotypes. This small trial showed a reduction in sputum eosinophil percentage by 4.5 times and may therefore be of benefit in patients with ABPA.Similarly, Fevipiprant, an antagonist of prostaglandin D2 receptor 2 has been shown to reduce eosinophilic airway inflammation in a randomised controlled trial of moderate – severe asthma patients. Several DARPins have been shown to be effective in vitro including DARPIN E2_79 and D11112. While the early results are promising and may be applicable for use in ABPA, further studies are required.Future potential therapeutics targeting IgE-mediated Th2 inflammation includes designed ankyrin proteins (DARPins) which prevent IgE-mediated activation of effector cells. They act to disrupt the formation of IgE/receptor complexes and break down formed complexes.In addition to anti-inflammatory and antifungal drugs, treatments that reduce mucus viscosity have been used to reduce the symptom burden in patients with ABPA. Hypertonic saline can be used  to reduce sputum viscosity and promote clearance, although no studies on long-term benefit have been performed.N-acetylcysteine; however, no ABPA-specific clinical trials have been performed. Dornase-alpha is potentially of benefit in ABPA, given the significant contribution of filamentous chromatin-rich EETs to sputum viscosity. A recent observational study of DNase use in the UK CF population showed modest long-term improvements in patients with lower lung function (FEV1 < 70% predicted) but was not able to distinguish any additional benefit in the ABPA subset. A recent case series reviewed the use of bronchoscopy with instillation of DNase in five patients with CF and ABPA who developed lobar atelectasis, and reported full lung re-expansion in all cases. However, it is possible that bronchoscopy and manual removal of secretions resulted in this good outcome rather than DNase use and further randomised trials are needed to determine the efficacy of DNase in ABPA.There are a number of other licenced mucoltyics available including nebulised Dornase-alpha and Allergy immunotherapy has been shown to be effective in atopic asthma and allergic rhinitis and is effective in preventing new allergen sensitivities. Small amounts of allergen are given sublingually or subcutaneously with the aim of inducing immunological tolerance which is maintained even after discontinuation of treatment. The first effect is the desensitisation of FcεR1 bearing mast cells and basophils, and this is followed by T-cell tolerance which is mediated by IL-10 and TGF-β. Immunotherapy has been shown to decrease nasal symptoms in allergic rhinitis and prevent progression to asthma.Aspergillus sp seen in ABPA. However, this treatment has a significant side effect profile including risk of anaphylaxis, with a reported systemic reaction to subcutaneous allergy immunotherapy of 0.1% per injection. Patients have been shown to require treatment monthly for at least 4 years to induce long-term benefit once treatment is discontinued. Sublingual immunotherapy has a better safety profile with similar efficacy. However, both routes of administration have significant issues with adherence, given the need for repeated doses.Immunotherapy may in the future have a role in reducing the allergic response to  Several TLR agonists have been investigated in the context of allergy immunotherapy and have shown efficacy in enhancing Th1 responses, although these data are largely from in vitro and animal models. Synthetic TLR4 and TLR9 agonists have been evaluated in clinical trials and synthetic TLR2, TLR5, and TLR7 have shown efficacy in human in vitro studies and animal in vivo studies. Similarly, monophosphoryl lipid A is an adjuvant that binds TLR4 and short segments of DNA with CpG motifs bind TLR 9. It may be possible in the future therefore to use TLR agonists as adjuvants in allergen immunotherapy directed against Aspergillus.TLR agonists have been investigated as adjuvant treatment in immunotherapy for common allergens involved in allergic rhinitis. They have been shown to favour an anti-allergic inflammatory profile favouring Th1 responses and when administered with allergens promote immunological tolerance. would be to initiate medium-dose steroid treatment or antifungals (itraconazole) in clinical stage 1, depending on patient factors and patient-specific risks for each treatment. Physiotherapy and mucolytic therapy as necessary should be instituted. Treatment response should be monitored initially at a 6- to 8-week interval with serum IgE levels, chest radiography, lung function, and quality-of-life questionnaires. The aim of therapy should be to reduce the IgE level by 25–50% and achieve clinical remission and stability. Steroids can then be reduced or tapered in remission (stage 2). A further exacerbation (stage 3) should be treated with either steroids alone or in combination with an antifungal . If the patient becomes treatment dependent (stage 5), alternative antifungals, pulsed methylprednisolone, nebulised amphotericin, or biologic agents could be considered.A suggested protocol for treatment of ABPAAspergillus sp, with failure in innate and adaptive immune systems resulting in reduced clearance of fungal spores from the airways and the ability for Aspergillus to form hyphae. This results in further Th2-weighted immune responses which in combination with substances secreted by Aspergillus itself, such as fungal proteases lead to airway hyper-responsiveness and excess mucus production, airway remodelling, inflammation, bronchiectasis, and fibrosis.ABPA is caused by an abnormal host response to The traditional treatments for ABPA focus on reducing the immune response with corticosteroids and reducing fungal burden with antifungal agents. However, despite this, a significant number of patients continue to suffer from active disease and exacerbations which cause further lung damage, bronchiectasis, and fibrosis. In addition, many of the current treatments have significant adverse effects which cause increased morbidity.Targeted immune treatments against aspects of the aberrant Th2 response have been shown to be effective and novel antifungal agents may be better tolerated and should be considered in patients with hard to treat disease or recurrent exacerbations. However, despite the potential role of novel biologic and antifungal therapies there is a critical lack of large-scale randomised control trials in ABPA which is a widespread global disease with significant health burden and morbidity. The current evidence for novel biologic and antifungal therapies is limited to case series and subgroups of larger trials, limiting the therapeutic options for patients. An understanding of disease heterogeneity in ABPA and endotypes will also be critical to ensure therapeutic stratification and success of future clinical trials.


Purpose: The importance of dental care and oral hygiene is often underestimated in people with autism spectrum disorder (ASD). Comorbidity with dental anxiety is greater in ASD subjects who also show unusual reactions to sensory stimuli. The aim of our study was to assess the efficacy for a sensory-adapted environment and targeted methods in reducing anxiety and positively influencing cooperation in children with ASD during a dental examination or specific treatments. Material and methods: The sample consisted of 50 Italian children with a diagnosis of ASD  presenting with mild intellectual disability (ID) and verbal language skills. The subjects enrolled in the study had at least two decayed teeth and all were treated in two different dental environments: regular dental environment (RDE) and sensory-adapted dental environment (SADE). Results: 20% of the sample was successfully treated in RDE, while 68% of subjects were successfully treated in SADE. Conclusions: Results suggest that a sensory-adapted environment positively affects the therapeutic dental treatment in patients with ASD and reaffirm that sensory dysregulation in children with ASD is a crucial factor influencing the successful outcome of oral care. Dental care and oral health are very important and are a crucial aspect in the overall health and quality of life for individuals. For some time now, the World Health Organization has stressed the importance of oral health among the health topics that each Member State should pursue. This topic, however, does not attract a great deal of attention and is often disregarded and undervalued in people with autism spectrum disorder (ASD) who present with abnormalities in communication, socialization, and restricted-repetitive behavioral patterns. Such difficulties, occurring in children from their earliest years of life and in different ways, are classified according to the severity of symptoms and are often associated with intellectual disability (ID). Moreover, these conditions may be associated with varying degrees of cognitive disability . People In a recent systematic review, Ismail et al. analyzed four studies assessing the effectiveness of SADE on children with special needs who received dental treatment. The studies analyzed showed that children with special needs treated in SADE make significant improvements in terms of physiological changes, behavior, pain, and sensory discomfort .In light of the aforementioned studies, the aim of the present study was to assess the efficacy for a sensory-adapted environment and targeted methods in reducing anxiety and positively influencing children with ASD to cooperate during a dental examination or specific treatments. Undergoing dental treatment is a challenge for children’s self-control and self-modulation skills. Children with ASD also adapt with greater difficulty to a normal dental setting because of their sensory anomalies. Hypo and hypersensitivity and the difficulty in discriminating between different sensorial channels can worsen the stress and anxiety perceived by ASD children when visiting a dentist, thus leading inevitably to a poor final outcome in the dental procedure. Therefore, the purpose of this study was to check whether a sensory-adapted dental environment may increase the percentage of ASD patients successfully treated for their class-1 caries.The study was approved by the local Ethical Committee of the Oasi Research Institute–IRCCS in Troina, Italy (CE17/06/2013 OASI). Written informed consent was obtained from the participants. The subjects were recruited among 55 patients referred to diagnostic and rehabilitation services at the Oasi Research Institute–IRCCS , a research institute dealing with treatment and rehabilitation in the field of intellectual disabilities.The inclusion criteria were: (a) a stable diagnosis of ASD made by expert qualified psychologists  followinExclusion criteria were: (a) patients with one permanent tooth with class-I caries or no permanent teeth with caries.Starting from 55 patients initially recruited, the sample was reduced to 50 patients because five of them had only one decayed tooth (exclusion criterion). Indeed, according to the study design, all patients should present with at least two decayed permanent teeth. In a first phase, they were brought to the RDE in order to try and treat one decayed permanent tooth and, subsequently, all patients were led to SADE to treat the second decayed permanent tooth. If we had recruited patients with only one decayed tooth, we would not have had the possibility in the second phase to be able to cure the second decayed tooth.-A regular dental environment (RDE);-A sensory-adapted dental environment (SADE).In our study, we used two different dental environments:The same dentist, with 20 years’ experience in the treatment of children with ASD, treated the two permanent teeth with class-I caries in the different dental environments. The two different dental environments are located in the Odontostomatology Unit of Oasi Research Institute–IRCCS in Troina.In contrast to the RDE, the SADE was provided with a screen to project movies, cartoons, or advertisements , soft lighting, and a sponge-coated dental turbine drill to minimize the noise. Firstly, all patients were treated in the RDE and, after two months, dental interventions were performed in the SADE.In the first phase in the RDE, the patient was seated on the dental chair and through the dental turbine, the class-1 cavity was removed and the filling was made with glass ionomer restorative material.In the second phase, the patient was transferred to the SADE with soft lighting. The patient was then seated on the dental chair while a screen projected movies, cartoons, or advertisements . By using a sponge-coated dental turbine drill to minimize the noise, the class-1 cavity was removed and, once removed, the resulting cavity was filled with glass ionomer restorative material .The dental treatments for 50 patients were scheduled one per day; therefore, the average time elapsed between the RDE and the SADE treatment was about two months.The study was carried out between January 2014 and April 2014. According to our a priori hypotheses, the adapted setting would have led to better results.N for a 2 × 2 chi-squared table is less than about 40, the Yates continuity correction was used. P values less than 0.05 were considered to be statistically significant. The statistical appropriateness of the chi-squared tests used in this study was assessed “a posteriori” by first calculating the effect size and then calculating the corresponding sample size required with α = 0.05, resulting in an actual power of 98% and a required sample size of 45 for the 2 × 2 matrix.The experimental design evaluated the differences between “before” and “after” by using a 2 × 2 contingency table McNemartest . Since the total The final sample for the study consisted of 50 patients , each with two permanent teeth with class 1-caries. All subjects received a stable diagnosis of ASD by expert qualified psychologists according to the DSM-5 criteria and after administration of C.A.R.S., ADOS, and ADI-R; moreover, they presented with mild ID (IQ ranging from 50 to 70) and verbal language skills in the absence of concomitant psychiatric and neurological pathologies.In the first phase of the study, all patients of the sample were taken in RDE. In this phase, 11 patients  were positively treated for class-1 caries of a permanent tooth; in the remaining 39 patients , this was not possible. In the second phase, the entire sample were led to SADE. During the SADE phase, 34 patients  were positively treated for class-1 caries of the second permanent tooth, while in 16 patients  it was not possible to treat the class-1 caries. . Furtherp-value < 0.0001). The duration of each treatment was not detected.Difference between the two groups (RDE vs. SADE) is statistically significant at the 0.05 level  and not for female patients .Statistical analyses were conducted to understand the statistical significance between RDE and SADE in females and males respectively. The results show a statistical significance for male patients  the sample examined was small and consisted mainly of males, (b) there was no control sample of children with typical development, (c) the evaluation in the effectiveness of the dental treatment was left exclusively to the dentist’s judgment.Moreover, all children in the sample were brought to a traditional dental environment to try and treat the class-1 caries, and at a later time they were brought to a sensory-adapted dental environment; therefore, in the second phase of the study, ASD children had already experienced the dental environment. This first phase, even if performed in a regular dental environment, may have favored a better compliance during the second experience regardless of the environment used. However, we believe that ASD individuals tend to crave sameness, thus a single experience is not enough to produce relevant habituation phenomena.Consistent with previous literature findings, the results from our study highlight that an adapted environment positively affects the therapeutic dental treatment performed on patients with ASD. Interestingly, the use of a SADE leads to significant successful treatment of caries in patients with ASD.For many children with ASD, dental care represents one of the main stressors, so parents tend to avoid dental examinations for their children, thus causing irreversible and irreparable damages over time.In a randomized crossover study performed by Cermak et al., 22 children with ASD and 22 typically developing children received two dental cleanings. One treatment was carried out in an RDE and the other was carried out in a SADE. Their results were similar to our study, showing positive benefits from interventions carried out in an adapted environment and patients, families, dentists, clinic staff, and investigators positively responded to the SADE experience .Watching a video serves as a distractor to efficiently reduce the anxiety associated with a non-collaborative behavior presented by a child with ASD. The use of soft lighting in a sensory-adapted environment minimizes the disruption from visual overstimulation ,19,20. TIn this context, it is important to also emphasize the role of the waiting room. A sensory-adapted waiting room environment seems to be less important in reducing the anxiety in typically developing children compared to other parameters, such as longer waiting time prior to treatment and visit purpose .Similarly, an appropriate design of dental waiting areas improves the waiting experience and reduces the preoperative anxiety before a dental appointment. For instance, the majority of children prefer waiting in a room with natural light, walls with pictures or posters, looking at an aquarium or watching television, listening to music, and the possibility to play ,25.Consistent with this evidence, at Oasi Research Institute, we chose not to keep children with ASD waiting in a traditional waiting room, but let them wait their turn in the playroom or in recreational spaces.Our results, in line with evidence in the scientific literature, suggest that a sensory-adapted environment positively affects the therapeutic dental treatment in male patients with ASD and reaffirm that sensory dysregulation in children with ASD is a crucial factor influencing the successful outcome in oral care. Future research studies, as well as the development and implementation of further environmental changes, are needed to obtain successful dental treatments for people with ASD with the aim of providing an experience with a greater perception of comfort, a strength in this particular population.Although parents of children with ASD tend to consider oral health less important than the primary disease, more attention is required for their oral healthcare through targeted approaches to improve the wellbeing of individuals and their families.


ABSTRACT IMPACT: Our findings could potentially identify CVD at-risk persons living with HIV who might benefit from aggressive risk-reduction. OBJECTIVES/GOALS: PWH have higher rates of CVD than the general population yet CVD risk prediction models rely on traditional risk factors and fail to capture the heterogeneity of CVD risk in PWH. Here we identify protein biomarkers that are able to discriminate between CVD cases and controls in PWH, and we assess their added benefit beyond traditional risk factors. METHODS/STUDY POPULATION: We analyzed 459 baseline protein expression levels from five OLINK panels in a matched CVD  case-control study with 390 PWH from INSIGHT trials . We formed 200 datasets via bootstrap. For each bootstrap set, a two-component partial least squares discriminant model (PLSDA) was fit. The importance of each variable in the discrimination of cases and controls in the PLSDA projection was assessed by the variable importance in projection (VIP) score. Proteins with average VIP scores > 1 were used in penalized logistic regression models with elastic net penalty, and proteins were ranked based on the number of times the protein had a nonzero coefficient. Proteins in the top 25th percentile were considered to have high discrimination. RESULTS/ANTICIPATED RESULTS: Participants had mean age 47 years, 13% were females, 4.9% had CVD at baseline and 69% were on ART at baseline. Eight proteins including the hepatocyte growth factor and interleukin-6 were identified as able to distinguish between CVD cases and controls within PWH. A protein score (PS) of the top-ranked proteins was developed using the bootstrap (for weights) and the entire data. The PS was found to be predictive of CVD independent of established CVD and HIV factors (Odds ratio: 2.17 CI: 1.58-2.99). A model with the PS and traditional risk factors had a 5.9% improvement in AUC over the baseline model (AUC=0.731 vs 0.69), which is an increase in model predictive power of 18%. Individuals with a PS above the median score were 3.1 (CI: 1.83- 5.41) times more likely to develop CVD than those with a protein score below the median score. DISCUSSION/SIGNIFICANCE OF FINDINGS: A protein score developed improved discrimination of PWH with CVD and those without, and helped identify PWH with high risk for developing CVD. If validated, this score and/or the individual proteins could be used in addition with established factors to identify CVD at-risk individuals who might benefit from aggressive risk-reduction.


Computational modeling is an essential component of modern drug discovery. One of its most important applications is to select promising drug candidates for pharmacologically relevant target proteins. Because of continuing advances in structural biology, putative binding sites for small organic molecules are being discovered in numerous proteins linked to various diseases. These valuable data offer new opportunities to build efficient computational models predicting binding molecules for target sites through the application of data mining and machine learning. In particular, deep neural networks are powerful techniques capable of learning from complex data in order to make informed drug binding predictions. In this communication, we describe Pocket2Drug, a deep graph neural network model to predict binding molecules for a given a ligand binding site. This approach first learns the conditional probability distribution of small molecules from a large dataset of pocket structures with supervised training, followed by the sampling of drug candidates from the trained model. Comprehensive benchmarking simulations show that using Pocket2Drug significantly improves the chances of finding molecules binding to target pockets compared to traditional drug selection procedures. Specifically, known binders are generated for as many as 80.5% of targets present in the testing set consisting of dissimilar data from that used to train the deep graph neural network model. Overall, Pocket2Drug is a promising computational approach to inform the discovery of novel biopharmaceuticals. Recent developments in genomics revealed novel disease-related molecular targets, many of which are yet to be characterized with respect to the possibility of modulating their functions with pharmaceutical agents. Another challenge in pharmacotherapy arises from resistance effects to existing drugs complicating the treatment of particularly infectious diseases  and cancTo make the drug discovery process more efficient, modern approaches incorporate miscellaneous computational components. Virtual screening (VS) is perhaps the most widely used strategy to help identify potentially bioactive molecules from large collections of commercially available as well as virtual compounds . Despitede novo drug discovery, where RNNs were trained to model the probability distribution of a drug dataset (Deep learning (DL) is a family of modern machine leaning models utilizing deep neural networks (DNNs). DL models have been demonstrated to be powerful feature extractors for ligand binding site classifiers  and metrge model , the pro dataset . These m(SMILES) , where iIn order to achieve this goal, we developed Pocket2Drug, a new deep generative model with the encoder-decoder architecture. Inspired by the framework of image captioning models taking images as the input to generate corresponding captions , the basPocket2Drug has a similar encoder-decoder architecture consisting of an encoder to extract features and a decoder to generate molecules. Nonetheless, Pocket2Drug differs from typical image captioning models in that it employs a graph representation of drug binding sites instead of images. Consequently, a GNN is employed as the encoder to extract the prior information from input pockets followed by an RNN decoder to generate molecule strings, which are the equivalents of image captions. In comprehensive benchmarking simulations against ligand-bound, ligand-free, and low-homology datasets of binding sites, we show that Pocket2Drug employing the encoder-decoder DNN effectively predicts binding drugs for input pocket structures.eFindSite   was usedBinding pockets are represented as graphs, in which nodes are non-hydrogen atoms and edges connect pairs of atoms spatially located within 4.5 Å from one another . Node fePocket2Drug is implemented in PyTorch v1.7.1  and emplThe GNN encoder extracts latent features from the input pocket graphs. We use the embedding network implemented in the GraphSite classifier as the feature extractor with the last fully connected layer removed and the remaining parts of the classifier employed as the feature extractor. The message passing function utilizes weighted neighbor node features, in which weights are generated by a two-layer, fully connected neural network taking edge features as the input. Updated node features in -network . The JK--network  to constAs a decoder, we use the gated recurrent unit (GRU), which is a variation of the vanilla RNN . The decDashed arrows in de novo drug design applications to learn the distribution of a drug dataset , another molecule tokenization scheme designed for machine learning applications . The SELPocket2Drug was trained on the Pocket2Drug-train dataset and validated against Pocket2Drug-holo, -apo, and -lowhomol datasets. We first analyze the size of molecules generated for the Pocket2Drug-holo dataset. de novo drug design.Next, the quality of molecules generated for the Pocket2Drug-holo dataset is evaluated using two complementing protocols, one based on the chemical similarity of binding molecules  and anotThe performance of Pocket2Drug, ZINC, and vanilla RNN are evaluated with the TC between the generated molecules and label ligands. For each pocket in the Pocket2Drug-holo dataset, TC values are calculated for a specified number of molecules sampled from the model output and the highest TC is selected as the final score. Next, the performance of Pocket2Drug is assessed against the Pocket2Drug-apo dataset. The mean root-mean-square deviation (RMSD)  of liganWe also evaluate the ability of Pocket2Drug to generalize to unseen data by measuring its performance against the Pocket2Drug-lowhomol dataset. As reported in d-allose binding protein (ALBP) from E. coli. MSK1 is involved in the regulation of mitogen activated kinases and it is required by the tumor-promoter-induced neoplastic cell transformation  and a sugar binding site in ormation . The comormation  was chosormation . Figure ormation , the dif2 in adenine, 3′ OH in pentose sugar, OH in ß-phosphate, NH linking ß- and γ-phosphates and OH in γ-phosphate in the complex crystal structure  transporter family facilitating the import and export of various molecules across the cell membrane  of 22 nm (Kd) of 100 nm (PDB-ID: 4nct)  . Figure D: 4nct) .Kd of 0.37 nm and has been tested for its anti-proliferative activity in the SF-268 cell line. It inhibits the viability of EphA2 growth dependent glioblastoma cells with a half-maximal effective concentration (EC50) of 5 μm (The second example is the human angiopoietin-1 receptor (Tie-2), an enzyme involved in vessel remodeling, branching, stability, and maturation . Using t of 5 μm . Despite of 5 μm . Docking of 5 μm .viz. those pockets extracted from proteins that are different from training instances. These findings are particularly important in drug discovery against novel protein structures, where it can help significantly reduce the search space of drug candidates. In contrast to traditional virtual screening typically employing a library of 200,000 to over 1,000,000 molecules , utilizing the RNN with the prior information , to the An attention mechanism was shown to significantly improve the performance of image captioning because it helps the model capture more semantically meaningful parts of images . We expe


Background: Carboplatin, the key drug used in treating gynaecological cancer, has an approximately 12–16% risk of hypersensitivity reactions. We aimed to investigate the efficacy and adverse effects of carboplatin desensitisation therapy for gynaecological cancer. Methods: The desensitisation protocol was standardised as a four-step, 4-h, carboplatin administration in the hospital. A retrospective medical record review was conducted on 15 patients who underwent carboplatin desensitisation for gynaecological malignancies at our hospital. Patients’ data were analysed to evaluate the treatment success rate, therapeutic effect of desensitisation, adverse events, and treatment. Results: Of 91 carboplatin desensitisation cycles scheduled; the completion rate was 93.4% (85/91). Adverse events occurred in 23 of these 91 (25.3%). In four (4.4%) of the 23 cycles, hypersensitivity reactions could be treated only by discontinuing the infusion and slowing the administration, while in the remaining 19 (20.9%), medication was administered intravenously after discontinuing the infusion to manage hypersensitivity reactions. No treatment-related deaths occurred. Overall, 23 series of anti-cancer agent regimens, including carboplatin desensitisation, were administered to the 15 patients. The therapeutic response rate was 82.6% and the disease control rate was 95.7%. Conclusions: Carboplatin desensitisation was beneficial in patients with a history of carboplatin-induced hypersensitivity reactions. Platinum agents are some of the most effective drugs for the treatment of gynaecological malignancies including ovarian, cervical, and endometrial cancers. Carboplatin, one of the platinum agents, is used most frequently. Compared to cisplatin, carboplatin demonstrates the same therapeutic efficacy with fewer adverse events  ,2. PlatiThe clinical symptoms of platinum HSRs range from mild to severe and death can also occur ,12,13. MHSRs to key drugs are problematic in some cases because of the lack of alternative therapies. Management options include enhanced premedication with antihistamines and corticosteroids, the discontinuation of carboplatin and switching to another drug, and carboplatin desensitisation (CD).The goal of desensitisation is for patients to react less strongly to chemotherapeutic agents. In some reports, CD was successful in patients who experienced platinum-related HSRs ,19,20,21The purpose of this study was to summarise the clinical features, toxicity, and effects of CD therapy on therapeutic efficacy, and outline possible appropriate prophylaxis and management strategies for treating the adverse events.We retrospectively evaluated the experience of CD in patients with gynaecological malignancies who experienced HSRs with previous chemotherapy. Our study was conducted at a teaching hospital attached to a university medical school, a general hospital with approximately 900 beds. This study was approved by the Institutional Review Board of Nippon Medical School (No. 30-01-1067). We reviewed all patients who underwent CD between January 2015 and December 2019. In this retrospective review study, only patients who underwent CD following careful consultation were included. That is, among all gynaecological cancer patients, only those who had developed HSRs because of carboplatin administration and who consented to the risk of undergoing desensitisation were included. Patients who developed HSRs to carboplatin and who consented to CD but for whom detailed information on HSRs was not available, and patients who had not completed an anti-cancer agent treatment cycle, including CD at our hospital, were excluded. Due to the nature of the disease, all subjects were female. Initial HSR symptoms varied and included, cutaneous symptoms ; respiratory symptoms ; cardiovascular symptoms ; gastrointestinal symptoms ; and atypical symptoms (limb dysesthesia and discomfort). Patients with adverse events associated with carboplatin administration were examined by oncologists. If the oncologist determined that their symptoms were carboplatin-induced HSRs, they were offered treatment alternatives, including CD therapy, another anti-cancer agent therapy, or best supportive care only. All patients understood the risks, including death, as well as the benefits of re-medication from the description of CD therapy, and they signed written informed consent for desensitization therapy. Consent to use the participants’ clinical information was obtained in writing and consent limited to this study was obtained by an opt-out method. After applying the inclusion and exclusion criteria, 15 patients with gynaecological malignancies  subsequently opted for CD at our hospital. None of the patients underwent treatment after developing HSRs at another hospital or underwent an intradermal reaction test for carboplatin.The desensitisation protocol followed at our institution was standardised as a four-step, 4-h, carboplatin administration based on the report by Takase et al.  That is,Under this desensitisation protocol, four different dilutions of carboplatin solutions were administered to patients over 1 h each. The total dose of carboplatin (AUC5-6 according to the regimen) was calculated using the Calvert formula. First, the total dose of carboplatin was dissolved in 250 mL of 5% glucose. Next, 25 mL of the solution were removed from the first solution and diluted with 225 mL of 5% glucose to obtain the second solution. This operation was repeated in sequence to prepare 1/10, 1/100, and 1/1000 diluted solutions. In other words, 250 mL of 0.1% solution, 225 mL of 1% solution, 225 mL of 10% solution, and 225 mL of 100% solution were prepared. Each solution was infused over 1 h, and all infusions were completed over 4 h. Prior to desensitisation, all patients were intravenously treated with glucocorticoids (dexamethasone 19.8 mg), H2 antagonists (famotidine 20 mg), H1 antagonists (chlorpheniramine 5 mg), and 5-HT3 antagonists  .If HSRs re-emerged during desensitisation, carboplatin administration was immediately discontinued, and the patient was examined by the attending doctor. After confirming the improvement of the symptoms, the patient was allowed to resume the treatment 30 min later. When the administration was resumed, it was re-initiated at half the infusion rate at the time of discontinuation, and if no abnormalities were observed for 30 min, the infusion rate was restored to the original rate. If a mild reaction occurred, careful observation of the symptoms was performed without medication. When a moderate reaction occurred, an H1 antagonist (chlorpheniramine 5 mg), an H2 antagonist (famotidine 20 mg), and glucocorticoid (hydrocortisone 100 mg or methylprednisolone 125 mg) were administered intravenously. In addition, a phosphodiesterase inhibitor (aminophylline 250 mg) was used to treat respiratory symptoms. For severe reactions or anaphylaxis, an additional 0.3 mg of adrenaline was administered in addition to the glucocorticoid. The gynaecological oncologist in charge decided whether to continue or discontinue the desensitisation depending on the symptoms of CHRs. If treatment continuation was an option, the patient was verbally consulted, and consent obtained. Even if the doctor-in-charge determined that continuous administration was possible, the administration was discontinued according to the patient wishes. Desensitisation was discontinued in all cases of severe hypersensitivity and anaphylaxis.The clinical-stage was evaluated based on the staging criteria of the International Federation of Gynaecology and Obstetrics. Therapeutic effects were evaluated according to the Revised Response Evaluation Criteria in Solid Tumours guidelines (version 1.1) . AdverseThe primary endpoint was the success rate of CD administration, which was calculated as the percentage of patients who completed all planned CDs among all patients and the percentage of completed CD cycles among the total CD cycles. The secondary endpoint was the response rate of the anti-cancer agent therapy, including CD. The treatment response rate was calculated as the percentage of consecutive treatments in which tumour shrinkage was observed in all consecutive treatments, including CD. An analysis using descriptive statistics was performed. The survey results were described and evaluated in terms of range, median, percentage, and so forth.2 . The initial HSR grades ranged from 1 to 3 .Patient characteristics are shown in n = 20), paclitaxel + carboplatin + bevacizumab (n = 30), docetaxel + carboplatin (n = 6), docetaxel + carboplatin + bevacizumab (n = 8), gemcitabine + carboplatin (n = 19), and gemcitabine + carboplatin + bevacizumab (n = 8).The chemotherapy regimens used for desensitisation were paclitaxel + carboplatin  were completed without adverse events. In 23 (25.3%) of the CD treatments, patients developed some CHRs, but symptoms were relieved by a temporary suspension of administration or additional medication; among those, 17 CD cycles were completed as planned. As a result, 85 CD cycles (93.4%) were completed as originally planned.Seven patients (46.7%) did not develop CHRs. Eight patients (53.3%) developed CHRs during the CD. Among them, three patients (20.0%) completed the scheduled treatment with only temporary interruptions or some changes in medication, while five patients (33.3%) discontinued the CD after consulting with their doctor. Treatment was not discontinued due to adverse events other than CHR or tumour exacerbation during the course of the treatment.After completing the series of regimens including CD, the therapeutic effect was determined by comparing tumour image measurements before and after treatment. A total of 23 series of anti-cancer agent regimens, including CD, were administered to the 15 patients. Results were evaluated according to the Response Evaluation Criteria in Solid Tumours (version 1.1) as complete response (CR) 15 series, partial response (PR) 4 series, stable disease (SD) 3 series, and progressive disease (PD) 1 series. The response rate [(CR + PR)/(CR + PR + SD + PD)] was 82.6%, and the disease control rate [(CR + PR + SD)/(CR + PR + SD + PD)] was 95.7%. The average platinum-free interval before the start of the anti-cancer treatment series, including the CD regimen, was 17.8 months  in 22 series, excluding one series of adjuvant therapy. Comparing the median platinum-free interval by treatment result, 14 series of CR was 19.5 (6–33) months, 4 series of PR was 14.5 (10–29) months, 3 series of SD was 10.0 (7–12) months, and 1 series of PD was 24 months.Adverse events were observed in 23 of the 91 total CD cycles (25.3%). In 4 (4.4%) of these cycles, CHRs could be treated only by discontinuing the infusion and slowing down the administration. In the remaining 19 cycles (20.9%), medication was administered intravenously after the discontinuation of the infusion to manage CHRs.Cutaneous adverse events were most common. Skin rash and itching were observed in seven patients; they were alleviated by discontinuation of CD or administration of additional drugs (grade 1 or grade 3). The next most commonly observed adverse events were those affecting the gastrointestinal system, such as stomach-aches and diarrhoea. Two patients developed symptoms and were treated with CD discontinuation and administration of H1 or H2 blockers (grade 1 or grade 3). One patient experienced grade 3 anaphylaxis (hypotension) but recovered quickly after discontinuing the carboplatin infusion, without requiring adrenaline and with no sequelae. Another patient experienced grade 3 anaphylaxis (bronchospasm and hypoxia) but quickly recovered with the addition of medications containing adrenaline. No treatment-related deaths occurred.We reported that carboplatin could be re-administered to patients who experienced CHRs, using the CD protocol. The therapeutic effect was satisfactory, and the recurrence of adverse events was in an acceptable range. This result is of great importance for patients; it stresses that prolonging their lives through additional carboplatin is feasible.Platinum agents, such as carboplatin, are essential for the treatment of gynaecological malignancies, especially ovarian cancer. However, multiple doses of carboplatin can cause HSRs, and abandoning subsequent platinum administration and switching to platinum-free anti-cancer therapy is of great detriment to a patient’s prognosis. CHRs usually appear in 8–19% of patients receiving repeated doses of six cycles or more (eight times on average) . CHRs arPreviously, unsuccessful attempts to re-administer the drug that caused HSR using premedication alone have been reported . On the In this study, we adopted a four-step, 4-h CD protocol in the hospital. The advantages of this protocol include its simplicity, short infusion times, and acceptable HSR rates . The CD The majority of our patient cohort completed the CD without experiencing serious adverse events. In our study, HSRs occurred in 25.3% of the CD cycles, which is close to the incidence of 25.0% reported in the largest desensitisation study by Altwerger et al. . OverallReviewing our results, discontinuation of CD was limited to 6 CD cycles, with 93.4% of cycles ending successfully. However, five patients did not complete the targeted number of CD cycles. Of the five dropouts, three were discontinued at the patient’s request. Strict adherence to our protocol rules meant that two patients failed CD, for a success rate of 86.7%. These two patients had initial CHRs with respiratory and circulatory symptoms and were at risk of developing severe adverse events during CD. As mentioned previously, we speculate that more stringent eligibility criteria for CD and exclusion of these two patients would have resulted in a higher success rate of desensitization, consistent with that reported by Li et al. .The discontinuation criteria in this study were not clear, and the decision to discontinue the CD depended on the judgment of the attending doctor, which could obscure the results of the analysis. In our study, two patients with CHR that affected their hemodynamic status and respiratory function discontinued CD and did not resume the subsequent CD cycle because of the strong expectation of more serious life-threatening adverse events. On the other hand, the three patients with milder symptoms also discontinued the subsequent CD cycle after consulting with their doctors, considering that the purpose of treatment for recurrent cancer was not curative. Lee et al. and Castells et al. allowed resumption of subsequent CD, even in patients who required adrenaline, corticosteroids, or oxygen, but Takase et al. did not ,19,22. TApart from the ambiguity of patient eligibility criteria and treatment discontinuation criteria mentioned above, the limitations of our study are its small sample size and retrospective nature. Because this was a retrospective study, patient characteristics were uncontrolled and varied in disease, stage, and the number of treatments. Therefore, in the future, it will be necessary to carefully consider the adaptation and discontinuation criteria, develop and comply with a protocol with unified standards, and conduct a large-scale investigation. In addition, the fact that male patients are not included in this study limited to gynaecologic cancers, will limit the versatility of this protocol. Although there are successful reports of CD on other types of cancer patients, that included males, using a protocol similar to ours, the findings derived from our study are limited to females ,42. As aIn conclusion, our findings suggest that CD is a good option for patients with a history of platinum-sensitive gynaecological cancer and CHR. CD carries some risk, but strict adaptation and discontinuation criteria may contribute to risk reduction. In addition, our improved protocol, which secures a day dedicated to carboplatin administration only, and which strictly regulates a slow administration, as a re-administration method after CHR, made it possible to administer CD more safely than the conventional protocols.


Maximum safe resection followed by chemoradiotherapy as current standard of care for WHO grade III and IV gliomas can be influenced by the occurrence of perioperative adverse events (AE). The aim of this study was to determine the association of AE with the timing and choice of subsequent treatments as well as with overall survival (OS).Prospectively collected data of 283 adult patients undergoing surgery for WHO grade III and IV gliomas at the University Hospital Zurich between January 2013 and June 2017 were analyzed. We assessed basic patient characteristics, KPS, extent of resection, and WHO grade, and we classified AE as well as modality, timing of subsequent treatment , and OS.In 117 patients (41%), an AE was documented between surgery and the 3-month follow-up. There was a significant association of AE with an increased time to initiation of subsequent therapy (p = 0.005) and a higher rate of interruption (p < 0.001) or non-initiation (p < 0.001). AE grades correlated with time to initiation of subsequent therapy (p = 0.038). AEs were associated with shorter OS in univariate analysis (p < 0.001).AEs are associated with delayed and/or altered subsequent therapy and can therefore limit OS. These data emphasize the importance of safety within the maximum-safe-resection concept. The current standard treatment for WHO grade III and IV gliomas is maximum safe resection followed by radiotherapy plus/minus concomitant and maintenance alkylating-based chemotherapy . PeriopeAE are considered to affect the course of further therapy and might lead to non-initiation, interruption, or delay of subsequent therapy and eventually to worse overall survival (OS) , 7. HoweHere, we analyzed the association between perioperative AE and both the timing of subsequent therapy as well as OS.We prospectively collected data from the patient registry of the Department of Neurosurgery at the University Hospital Zurich . We screAll included patients underwent initial neurosurgical intervention for WHO grade III or IV glioma. The extent of resection (EOR) varied between biopsy-only, partial resection <98%, and gross total resection ≥98%. The protocol of subsequent therapy during the study period was based on the EANO guideline from 2014 . The staParameters extracted from the patient registry were age, sex, functional state, EOR, WHO grade, length of hospital stay (LOS), procedure and timing of subsequent therapy, any delay or interruption or non-initiation of the subsequent therapy protocol, the occurrence of AE, and OS. The patients’ functional state was quantified using the Karnofsky Performance Status (KPS). A worsened functional state was defined as a decrease in the KPS 3 months postoperatively compared to the preoperative KPS. EOR was assessed by three-dimensional volume measurements of pre- and <72 h postoperative MRI scans using Smartbrush application of Brainlab Elements, Brainlab AG Munich. In case of lacking MRI data, EOR was not further evaluated.Perioperative AE with its corresponding clinical diagnosis were assessed using the Clavien–Dindo Grade (CDG) classification and graded accordingly Table 1 We defined the variable “altered subsequent therapy” as the occurrence of either a delay, interruption, or non-initiation of the subsequent therapy. The time to initiation of subsequent therapy was defined as duration between the intervention and the beginning of subsequent therapy. A delay in subsequent therapy was defined as a duration of >42 days until initiation. Any interruptions of therapy were additionally registered and defined as any break in the protocol of subsequent therapy. The non-initiation of subsequent therapy was defined as the absence of subsequent chemo- and radiotherapy.OS was defined as the time from surgery until death or the last date when the patient was known to be alive.2 tests, correlations using Spearman correlation tests, OS using Kaplan–Meier and log-rank tests, and multivariate analysis using Cox’s proportional hazard model. Hazard ratios (HR) are given with 95% confidence intervals (CI).The patient registry is based on FileMaker Pro version 13.0. For statistical analysis, IBM SPSS Statistics v24 and MATLAB R2019a were used. A p-value of ≤0.05 was considered statistically significant. Continuous data were analyzed with two-tailed Mann–Whitney U tests and Student’s t-tests and categorical data with two-sided Pearson χThe local ethics committee  approved prospective data collection in the patient registry and waived patient consent due to the observational nature of the study (PB-2017-00093). The study was registered at clinicaltrials.gov (NCT01628406).Two hundred eighty-three patients were included in our study. The main clinical characteristics and outcome data of the study group stratified for AE are depicted in The mean time to initiation was significantly higher for patients with AE prior to therapy  and correlated significantly with the grade of AE  with a slope of -9.5 KPS points per increment of CDG in the linear fit Figure 2OS for patients with AE was shorter  . There was a trend toward shorter OS in patients with AE with HR = 1.32 (CI 0.96–1.77), although this did not reach statistical significance (p = 0.063). Altered subsequent therapy had a stronger and significant association with shorter OS  Table 3.There is only scarce information about the frequency and the exact clinical repercussions of AE in glioma surgery. The risk of AE in the resection of WHO grade III and IV glioma is relatively high due to the difficult balancing between a maximal tumor resection and new postoperative neurological deficits and other AE . TherefoThe impact of timing of subsequent therapy on OS is still unclear. Nevertheless, different studies indicate that a delay of >42 days should be avoided –12. We oRegarding OS, patients with AE had significantly decreased median survival in a univariate analysis in line with findings of previous studies , 7. In aAs a retrospective analysis of prospectively collected data, our study is subjected to the general limitations of retrospective studies. Still, our outcome data was collected prospectively and modified retrospectively only in case of incompleteness, which minimized the risk of information bias. It has to be taken into account that some patients already started subsequent therapy within the 3-month period in which AE were measured. Thus, it cannot be excluded that some of the AE might also be due to subsequent therapy and are not related to surgery. Although the majority of AE occurred in close temporal proximity to the surgical intervention and measured AE are almost exclusively logically attributed to surgery rather than subsequent therapy, this limitation has to be considered. Furthermore, one must keep in mind that the lower patient age and better KPS preoperatively for patients without an AE as well as molecular tumor markers play a major role in prognosis and OS in high-grade glioma patients and can therefore interfere with our results, which poses another source of limitation for our study.Future projects should incorporate the new 2021 WHO classification of brain tumors and should also reflect measurements for AE severity such as the Therapy–Disability–Neurology Grading as well as measures for the presurgical factors such as initial patient status or the complexity of the tumor surgery such as the Milan Complexity Score .In conclusion, our results support the hypothesis that AE reduce the rate of successful and uninterrupted chemoradiotherapy and ultimately limit OS. While this association seems intuitively true, our study now supports it with data from a large patient cohort. In the sensitive balancing act between maximal resection and postoperative neurological function, our study quantifies the risk of causing AE and by that a possible impairment of the course of subsequent therapy and OS. Therefore, these findings have implications in risk stratification and quality management of WHO grade III and IV glioma surgery.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.This study was reviewed and approved by Kantonale Ethikkommission Zürich, Stampfenbachstrasse 121, 8090 Zürich, Switzerland. The ethics committee waived the requirement of written informed consent for participation due to the observational nature of the study.Study design: LW, JS, MN. Data acquisition: LW, TM, JV, FV, SV, LP, JS, MN. Statistical analysis: LW, LP. Interpretation: all authors. Writing of original draft: LW, L P. Review and revision: all authors. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.